Vol 24 No 2 May - August 2014 °√≥’»÷°…“ : Õ“°“√‰¡àæ÷ߪ√– ß§å 97

97 Õ¬à“ß√ÿπ·√ß®“° L-asparaginase

Medication Safety

§Õ≈—¡πåπ’È𔇠πÕ∫∑§«“¡®“°ª√– ∫°“√≥å·≈–§«“¡√Ÿâ∑’ËΩÉ“¬‡¿ —™°√√¡ ‚√ß欓∫“≈»‘√‘√“™ π”¡“

·∫àߪíπ·°à‡¿ —™°√‚√ß欓∫“≈·≈–∫ÿ§≈“°√∑’Ë π„® ‡æ◊ËÕ„À⇰‘¥°“√¢¬“¬§«“¡√Ÿâ¥â“πµà“ßÊ ∑’ˇ°’ˬ«¢âÕß
°—∫†Medication Safety ·≈–¬‘π¥’‡ªî¥√—∫∫∑§«“¡®“°‡¿ —™°√‚√ß欓∫“≈Õ◊ËπÊ ∑’Ë π„® à߇¢â“√à«¡
·∫àߪíπ¥â«¬††‚¥¬¡ÿàßÀ«—ß∑’Ë®– à߇ √‘¡„À⇿ —™°√¡’∫∑∫“∑„π°“√∑”„À⇰‘¥§«“¡ª≈Õ¥¿—¬®“°°“√„™â¬“‰¥â
°«â“ߢ«“߬‘Ëߢ÷Èπ

°√≥’»÷°…“ : Õ“°“√‰¡àæ÷ߪ√– ß§åÕ¬à“ß√ÿπ·√ß®“° L-asparaginase

L-asparaginase Induced Anaphylaxis: Case Report
°¡≈«√√≥ æ—¥»√’‡√◊Õß, ¿.∫.*

∫∑π” Õ–¡‘‚π·Õ æ“√“®’π (asparagine, ASN) „À⇪ìπ

Asparaginase (ASNase) ‡ªì𬓵â“π¡–‡√Áß
∑’Ë„™â„π°“√√—°…“¡–‡√Á߇¡Á¥‡≈◊Õ¥¢“«∑—Èß„π√–¬–™—°π”
„Àâ‚√§ ß∫ (induction of remission) ´÷Ë߇ªìπ°“√„Àâ
¬“‡§¡’∫”∫—¥Õ¬à“߇µÁ¡∑’Ë ‡æ◊ÕË ∑”≈“¬‡´≈≈å¡–‡√Áß„Àâ¡“°
∑’Ë ÿ¥„π‡«≈“Õ—π√«¥‡√Á«∑’Ë ÿ¥ ‡æ◊ËÕ„À≢°√–¥Ÿ° “¡“√∂
°≈—∫¡“ √â“߇´≈≈凡Á¥‡≈◊Õ¥ª°µ‘‰¥â‡À¡◊Õπ‡¥‘¡ ·≈–
√–¬–√—°…“‡¢â¡¢âπ (intensification or consolidation
therapy) ∑’Ë ‡ ªì π °“√„Àâ ¬ “‡§¡’ ∫”∫— ¥ Õ¬à “ ߇¢â ¡ ¢â π
À≈—ß®“°°“√„À⬓‡§¡’∫”∫—¥„π√–¬–·√°√à«¡°—∫°“√„Àâ
¬“‡§¡’∫”∫—¥™π‘¥Õ◊ËπÊ ‡æ◊ËÕ¶à“‡´≈≈å¡–‡√Áßµ—«ÕàÕπ∑’ˬ—ß
‡À≈◊ÕÕ¬Ÿà·≈–ªÑÕß°—π°“√‡æ‘Ë¡®”π«π¢Õ߇´≈≈å¡–‡√Áß
‡¡Á¥‡≈◊Õ¥¢“«∑’Ë¥◊ÈÕµàÕ¬“‡§¡’∫”∫—¥ ¡’°“√»÷°…“æ∫«à“
°“√„™â¬“ ASNase ‡ªì𬓇¥’ˬ«„π°“√√—°…“ “¡“√∂
∑”„Àâ‚√§ ß∫ (remission rate) ‰¥â√âÕ¬≈– 40-
60 ·≈–‡æ‘Ë¡™à«ß√–¬–‡«≈“∑’Ë‚√§ ß∫ (duration of
remission) 䴉1,2,3
¬“ ASNase ÕÕ°ƒ∑∏‘Ï ‚ ¥¬°“√ ≈“¬°√¥
* Àπ૬·æ⬓ ΩÉ“¬‡¿ —™°√√¡ ‚√ß欓∫“≈»‘√‘√“™
°√¥·Õ æ“µ‘° (aspartic acid) ·≈–·Õ¡‚¡‡π’¬ ‡´≈≈å
¡–‡√Á ß ·≈–‡´≈≈å ‰ ¢°√–¥Ÿ ° ´÷Ë ß ª°µ‘   √â “ ß ASN „π
ª√‘¡“≥πâÕ¬¡“° ‡¡◊ËÕ ASN ∂Ÿ° ≈“¬·≈–‰¡à “¡“√∂
 √â“ß∑¥·∑π‰¥â∑—π ®÷߉¡à “¡“√∂ √â“ß‚ª√µ’π‰¥â ¡’º≈
¬—∫¬—Èß°“√ √â“ß RNA ·≈– DNA  àߺ≈„À⇴≈≈å
¡–‡√Áßµ“¬À√◊ÕÀ¬ÿ¥°“√‡®√‘≠‡µ‘∫‚µ4
º≈‘µ¿—≥±å¬“ ASNase ∑’Ë¡’®”Àπà“¬„πªí®®ÿ∫—π
¡’ 3 ·∫∫ §◊Õ native Escherichia coliaspara-
ginase (L-ASNase), pegaspargase ·≈– Erwinia
asparaginase ‚¥¬¡’§à“§√÷Ëß™’«‘µ¢Õ߬“ ¢π“¥·≈–
§«“¡∂’„Ë π°“√„À⬓∑’·Ë µ°µà“ß°—π5,6 ¥—ß· ¥ß„πµ“√“ß 1
Õÿ∫—µ‘°“√≥å„π°“√‡°‘¥°“√·æ⬓ ASNase ∑—Èß 3 ·∫∫
æ∫«à“ L-ASNase ·≈– pegaspargase ¡’Õÿ∫—µ‘°“√≥å
„°≈⇧’¬ß°—π  à«π Erwinia asparaginase ¡’Õÿ∫—µ‘-
°“√≥å°“√·æâπâÕ¬°«à“ ‡π◊ËÕß®“°¡’°“√»÷°…“ π—∫ πÿπ
«à“√Ÿª·∫∫¬“∑’ˉ¥â®“°·∫§∑’‡√’¬™π‘¥ E. Coli °√–µÿâπ
hypersensitivity reaction (HSRs) ¡“°°«à“6
98  ¡“§¡‡¿ —™°√√¡‚√ß欓∫“≈ (ª√–‡∑»‰∑¬) «“√ “√‡¿ —™°√√¡‚√ß欓∫“≈

µ“√“ß 1 ‡ª√’¬∫‡∑’¬∫§«“¡·µ°µà“ߢÕߺ≈‘µ¿—≥±å¬“ asparaginase (ASNase) ∑’Ë¡’®”Àπà“¬

™◊ËÕ “¡—≠ L-Asparaginase (native Pegaspargase (Pegylated Asparaginase
Escherichia coliasparaginase) Escherichia coliasparaginase) Erwinia chrysanthemi
™◊ËÕ°“√§â“ Elspara Oncasparb Erwinazeb
 à«πª√–°Õ∫ ª√–°Õ∫¥â«¬‡Õπ‰´¡å L-ASNase ª√–°Õ∫¥â«¬ L-ASNase ∑’Ë®—∫°—∫ ª√–°Õ∫¥â«¬‡Õπ‰´¡å L-ASNase
monomethoxypolyethylene
glycol ¥â«¬æ—π∏–‚§«“‡≈πµå
™π‘¥¢Õß Escherichia coli Escherichia coli Erwinia chrysanthemi
·∫§∑’‡√’¬ (E. coli) (formerly Erwinia carotovora)
∑’˺≈‘µ
§à“§√÷ßË ™’«µ‘ 1.28±0.35 5.73±3.24 0.65±0.13
(«—π±§à“
‡∫’ˬ߇∫π
¡“µ√∞“π)
√Ÿª·∫∫¬“ ºß¬“√–‡À‘¥·Àâß  “√≈–≈“¬ ºß¬“√–‡À‘¥·Àâß
¢âÕ∫àß„™â c ‡ªìπ à«πÀπ÷ËߢÕß°“√„À⇧¡’∫”∫—¥ ‡ªìπ à«πÀπ÷ËߢÕß°“√„À⇧¡’∫”∫—¥ ‡ªìπ à«πÀπ÷ËߢÕß°“√„À⇧¡’∫”∫—¥
„π°“√√—°…“ºŸâªÉ«¬ ALL „π°“√√—°…“ºŸâªÉ«¬ ALL ‚¥¬Õ“® „π°“√√—°…“ºŸâªÉ«¬ ALL ∑’Ë·æâ
„™â‡ªìπ∑“߇≈◊Õ°·√°„π°“√√—°…“ L-ASNase ∑’Ë∑”®“° E. coli
·≈–„™â„πºŸâªÉ«¬∑’Ë·æâ L-ASNase
¢π“¥¬“ c ©’¥‡¢â“°≈â“¡‡π◊ÈÕÀ√◊Õ©’¥‡¢â“À≈Õ¥ ©’¥‡¢â“°≈â“¡‡π◊ÈÕÀ√◊Õ©’¥‡¢â“À≈Õ¥ - „™â·∑π L-ASNase:
‡≈◊Õ¥¥” 6,000 IU/m2 3 §√—Èß/ ‡≈◊Õ¥¥” 2,500 IU/m2 3 §√—Èß ©’¥‡¢â“°≈â“¡‡π◊ÈÕ 25,000 IU/m2
 —ª¥“Àå ∑ÿ° 2  —ª¥“Àå ‚¥¬„Àâ·∑π L-ASNase ∑’Ë
«“ß·ºπ„π°“√√—°…“
- 㪉᷹ pegaspargase:
©’¥‡¢â“°≈â“¡‡π◊ÈÕ 25,000 IU/m2
3 §√—Èß/ —ª¥“Àå·≈–„Àâ 6 §√—Èß
·∑π°“√„Àâ pegaspargase
∑’Ë«“ß·ºπ„π·µà≈–§√—Èß
a
„πª√–‡∑»‰∑¬¡’™◊ËÕ°“√§â“ §◊Õ Leunase
b
‰¡à¡’„πª√–‡∑»‰∑¬
c
Õπÿ¡—µ‘‚¥¬Õߧ尓√Õ“À“√·≈–¬“·Ààߪ√–‡∑» À√—∞Õ‡¡√‘°“
ALL = acute lymphoblastic leukemia; IU = international unit; m2 = square meter

Õ“°“√‰¡àæ÷ߪ√– ß§å¢Õß ASNase ¡’∑—Èß∑’ˇ°‘¥ Õ“°“√‰¡àæ÷ߪ√– ß§å∑’Ë∑”„À≡ࠓ¡“√∂„™â¬“µàÕ‰¥â §◊Õ

ºà“π√–∫∫¿Ÿ¡‘§ÿâ¡°—π·≈–‰¡àºà“π√–∫∫¿Ÿ¡‘§ÿâ¡°—π ¥—ß
· ¥ß„πµ“√“ß 2 Õ“°“√‰¡àæ÷ߪ√– ß§å∑’ˉ¡àºà“π√–∫∫
¿Ÿ¡‘§ÿâ¡°—πÀ√◊Õº≈¢â“߇§’¬ß®“°¬“π—Èπ ‰¥â·°à Õ“°“√
ª«¥∫«¡∫√‘‡«≥∑’©Ë ¥’ ª«¥∑âÕß ∑âÕ߇ ’¬ ™“ª≈“¬π‘«È ¡◊Õ
·π«∑“ß„π°“√®— ¥ °“√ §◊ Õ √— ° …“µ“¡Õ“°“√·≈–
 “¡“√∂„À⬓µàÕ‰¥â®π§√∫ ‰¡à®”‡ªìπµâÕßÀ¬ÿ¥¬“  à«π
°“√‡°‘¥¿“«–¿Ÿ¡‘§ÿâ¡°—π‰«‡°‘π HSRs ‡π◊ËÕß®“°Õ“°“√
®–√ÿπ·√ß·≈–∑”„À⺟âªÉ«¬¡’Õ—πµ√“¬∂÷ß·°à™’«‘µ‰¥â
°“√‡°‘¥ HSRs ®“°¬“ ASNase æ∫Õÿ∫—µ‘-
°“√≥å Ÿß∂÷ß√âÕ¬≈– 25 - 357 ‚¥¬¡’°≈‰°°“√·æâºà“π
B cell °√–µÿâπ·Õπµ‘∫Õ¥’™π‘¥ IgG ‡ªìπÀ≈—° ·µà
∫“ß°“√»÷°…“æ∫«à“°√–µÿâπ·Õπµ‘∫Õ¥’™π‘¥ IgE ·≈–
Vol 24 No 2 May - August 2014 °√≥’»÷°…“ : Õ“°“√‰¡àæ÷ߪ√– ß§å 99
Õ¬à“ß√ÿπ·√ß®“° L-asparaginase

µ“√“ß 2 Õ“°“√‰¡àæ÷ߪ√– ß§å®“°°“√„À⬓ L-ASNase (¢âÕ¡Ÿ≈‰¥â®“°√“¬ß“π°“√»÷°…“∑’Ë∑”„πºŸâªÉ«¬‡¥Á°‰∑¬

®”π«π 33 √“¬)4
ºŸâªÉ«¬
Õ“°“√‰¡àæ÷ߪ√– ß§å
®”π«π (√“¬) √âÕ¬≈–
º◊πË ≈¡æ‘… 6 18.19
∑âÕ߇ ’¬ 5 15.16
ª«¥∫«¡·¥ß∫√‘‡«≥∑’Ë©’¥ 5 15.16
ª«¥∑âÕß 5 15.16
anaphylaxis 3 9.09
µ—∫ÕàÕπÕ—° ∫ 3 9.09
º◊ËπÀ“¬‡Õß„π 15 π“∑’ 2 6.06
™“ª≈“¬π‘È«¡◊Õ 1 3.03
left hemipariasis 1 3.03
º◊Ëπ·≈– neutropenia 1 3.03
Àπâ“ µ“ ª“°∫«¡ 1 3.03
√«¡ 33 100
°“√¥”‡π‘π°“√·°â‰¢·≈–ªÑÕß°—π
À¬ÿ¥°“√„À⬓ 3 √“¬·≈–ÕÕ°∫—µ√·æ⬓
„À⬓µàÕ®π§√∫ 3 √“¬ („Àâ premedication 1 √“¬)
√—°…“µ“¡Õ“°“√·≈–„À⬓µàÕ®π§√∫
√—°…“µ“¡Õ“°“√·≈–„À⬓µàÕ®π§√∫
√—°…“µ“¡Õ“°“√·≈–„À⬓µàÕ®π§√∫
À¬ÿ¥°“√„À⬓·≈–ÕÕ°∫—µ√·æ⬓
À¬ÿ¥°“√„À⬓·≈–ÕÕ°∫—µ√·æ⬓
√—°…“µ“¡Õ“°“√·≈–„À⬓µàÕ®π§√∫
√—°…“µ“¡Õ“°“√·≈–„À⬓µàÕ®π§√∫
√—°…“µ“¡Õ“°“√·≈–À¬ÿ¥°“√„À⬓
√—°…“µ“¡Õ“°“√·≈–À¬ÿ¥°“√„À⬓
À¬ÿ¥°“√„À⬓·≈–ÕÕ°∫—µ√·æ⬓

IgM ¥â«¬ ‚¥¬Õ“°“√· ¥ß¢Õß°“√·æâ ‰¥â·°à º◊Ëπ
≈¡æ‘… Àπâ“ µ“ ª“°∫«¡ ·πàπÀπâ“Õ° À“¬„®≈”∫“°
§«“¡¥—π‡≈◊Õ¥µ° ·≈–Õ“®√ÿπ·√ß∂÷ß anaphylaxis
·≈–¡—°æ∫«à“ anaphylaxis  —¡æ—π∏å°—∫°“√°√–µÿâπ
·Õπµ‘∫Õ¥’™π‘¥ IgE5 ®“°π—Èπ‡¡◊ËÕ‡Àπ’ˬ«π”„À⇰‘¥
IgE-mediated ®–°√–µÿâπ mast cell „Àâ¡’°“√À≈—Ëß
histamine ·≈–· ¥ßÕ“°“√·æâ  Õ¥§≈âÕß°—∫º≈°“√
»÷°…“¢Õß°≈ÿà¡ß“π‡¿ —™°√√¡  ∂“∫—π ÿ¢¿“懥Á°
·Ààß™“µ‘¡À“√“™‘π’ ∑’Ëæ∫«à“ºŸâªÉ«¬‡¥Á°‰∑¬®”π«π 33
√“¬∑’ˉ¥â√—∫ L-ASNase ‚¥¬°“√©’¥‡¢â“°≈â“¡‡π◊ÈÕ ‡°‘¥
HSRs √«¡ 10 √“¬ (√âÕ¬≈– 30.31) ‚¥¬¡’º◊Ëπ≈¡æ‘…
µ“√“ß 3 Õ“°“√· ¥ß·∫àߧ«“¡√ÿπ·√ßµ“¡ NCI Common Terminology Criteria for Adverse Events v3.0
Grade (√–¥—∫§«“¡√ÿπ·√ß)
1 2
Õ“°“√·æâ -†Àπâ“·¥ß - º◊Ëπ
(allergic reaction or -†º◊Ëπ -†Àπâ“·¥ß
hypersensitivity) -†‰¢â < 38 Ì´ -†º◊Ëπ≈¡æ‘…
-†À“¬„®≈”∫“°
-†‰¢â ≥ 38 Ì´
NCI = National Cancer Institute
6 √“¬, anaphylaxis 3 √“¬ ·≈– Àπâ“ µ“ ª“°∫«¡ 1
√“¬8 ‚¥¬§«“¡‡ ’ˬߢÕß°“√‡°‘¥°“√·æⵓ¡°“√»÷°…“
¢Õß Woo ·≈–§≥– æ∫«à“¡—°Õ¬Ÿà„π√–¬–√—°…“‡æ◊ËÕ
§«∫§ÿ¡„Àâ‚√§ ß∫µ≈Õ¥‰ª (maintenance therapy)
·≈–√–¬–°“√™—°π”„Àâ‚√§ ß∫Õ’°§√—ßÈ (reinduction of
remission) ‚¥¬®–·æâ‡æ‘¡Ë ¢÷πÈ À≈—ßÀ¬ÿ¥„À⬓լà“ßπâÕ¬
1 ‡¥◊Õπ ·≈â«°≈—∫¡“„Àâ´È”Õ’°„πºŸâªÉ«¬ relapse ALL
·≈–„π°“√»÷°…“æ∫«à“¡—°‡°‘¥À≈—ß°“√„À⬓§√—Èß∑’Ë 12
‡ªìπµâπ‰ª9  ”À√—∫Õ“°“√· ¥ßÕ“®·∫àߧ«“¡√ÿπ·√ß
µ“¡ NCI Common Terminology Criteria for
Adverse Events v3.0 ¥—ß√“¬≈–‡Õ’¬¥„πµ“√“ß 3
3 4 5
-†À≈Õ¥≈¡À¥ Õ“®¡’/ anaphylaxis ‡ ’¬™’«‘µ
‰¡à¡’º◊Ëπ≈¡æ‘…√à«¡¥â«¬
-†∫«¡
-†§«“¡¥—πµË”
100  ¡“§¡‡¿ —™°√√¡‚√ß欓∫“≈ (ª√–‡∑»‰∑¬)
·π«∑“ß°“√®—¥°“√‡¡◊ËÕ‡°‘¥ HSRs §◊Õ À¬ÿ¥
°“√„Àâ ¬ “·≈–„Àâ ¬ “√— ° …“µ“¡Õ“°“√¢ÕߺŸâ ªÉ « ¬ ¡’
¢â Õ ¡Ÿ ≈ °“√„Àâ antihistamine À√◊ Õ steroid ‡ªì π
premedication  ”À√—∫°“√„À⬓§√—Èß∂—¥‰ª„πºŸâªÉ«¬
∑’Ë ‡ °‘ ¥ HSRs ∑’Ë ¡’ √ –¥— ∫ Õ“°“√√ÿ π ·√ßπâ Õ ¬ æ∫«à “
 “¡“√∂„Àâ ¬ “‰¥â ‚ ¥¬‰¡à ‡ °‘ ¥ HSRs ·µà ¡’ ∫ “ß°“√
»÷°…“‰¡à·π–π”„Àâ antihistamine À√◊Õ steroid ‡ªìπ
premedication ‡π◊ËÕß®“°¬“‡À≈à“π’È®–‰ª∫¥∫—ß°“√
∑”ß“π¢Õß antibodies ´÷Ëß≈¥ª√– ‘∑∏‘¿“æ¢Õ߬“
·µà„πºŸâªÉ«¬∑’Ë¡’Õ“°“√√ÿπ·√ß°“√„Àâ premedication
°ÁÕ“®¬—߇°‘¥ HSRs ¥—ßπ—Èπ °“√∑” desensitization
À√◊Õ°“√„Àâ pegaspargase ·≈– Erwinia asparagi-
nase ‡ªìπ∑“߇≈◊Õ°„π°√≥’∑’˺ŸâªÉ«¬·æâ L-ASNase
®÷ßÕ“®ª≈Õ¥¿—¬ ”À√—∫ºŸâªÉ«¬¡“°°«à“5,6
°√≥’ »÷ ° …“µà Õ ‰ªπ’È ® –°≈à “ «∂÷ ß Õ“°“√‰¡à æ÷ ß
ª√– ß§å∑’ˇ°‘¥ºà“π√–∫∫¿Ÿ¡‘§ÿâ¡°—π¢Õ߬“ L-ASNase
·≈–·π«∑“ß„π°“√®—¥°“√ºŸâªÉ«¬‡æ◊ËÕ‡ªìπ·π«ªØ‘∫—µ‘
µàÕ‰ª
√“¬ß“πºŸâªÉ«¬
ºŸâªÉ«¬À≠‘߉∑¬‚ ¥ Õ“¬ÿ 22 ªï √Ÿâ ÷°µ—«¥’
Õ“°“√ ”§—≠: ºŸâªÉ«¬¡’ urticarial rash ∑’ËΩÉ“¡◊Õ
ª“° „∫ÀŸ µâπ§Õ ·≈–¢“ ¡’µ“∫«¡ ¡’·πàπ§Õ ®ÿ°·πàπ
Àπâ“Õ° À“¬„®‰¡àÕÕ°
ª√–«—µ‘°“√‡®Á∫ªÉ«¬·≈–°“√„™â¬“„πÕ¥’µ: 5 ªï
°àÕπ ºŸâªÉ«¬¡’‰¢â Ÿß ÕàÕπ‡æ≈’¬ ‡Àπ◊ËÕ¬ßà“¬‡«≈“ÕÕ°
·√ß ´’ ¥ µ√«®æ∫ pancytopenia, ‰¥â √— ∫ °“√∑”
bone marrow biopsy æ∫ extensively involved
by acute leukemia ·≈–‰¥â√—∫°“√√—°…“‡√‘Ë¡¥â«¬
ALL protocol induction phase (doxorubicin,
vincristine, L-ASNase, prednisolone) µ“¡¥â«¬
consolidation phase 2 ‡ªìπ‡«≈“ 1 ªï À≈—ß®“°π—Èπ
‰¥â∑” allogenic stem cell transplantation ·≈â«
Õ“°“√¥’¢÷Èπ ®“°π—ÈπÕ’° 3 ªï ¡“µ√«®æ∫ relapse
«“√ “√‡¿ —™°√√¡‚√ß欓∫“≈
acute leukemia ®÷ßπ—¥¡“√—∫¬“‡§¡’∫”∫—¥µàÕ ‚¥¬„Àâ
 Ÿµ√ Hyper-CVAD ®π§√∫ ·µà¬—ßæ∫ relapse
acute leukemia Õ’° ®÷ß„Àâ Ÿµ√ FLAG-IDA ·µà
º≈°“√√— ° …“‰¡à µ Õ∫ πÕßµà Õ  Ÿ µ √¬“‡§¡’ ∫”∫— ¥ ∑’Ë „ Àâ
®÷߇ª≈’Ë¬π¡“„Àâ cyclophosphamide, vincristine,
L-ASNase, dexamethasone º≈°“√„À⬓„π cycle
∑’Ë 1 ‰¡àæ∫Õ“°“√¢â“߇§’¬ß„¥Ê
ª√–«—µ°‘ “√‡®Á∫ªÉ«¬·≈–°“√√—°…“„πªí®®ÿ∫π— : ºŸªâ «É ¬
¡’ relapse ALL ¡“√—∫¬“‡§¡’∫”∫—¥µ“¡·æ∑¬åπ—¥
„À⇪ìπ palliative chemotherapy §√—Èßπ’ȺŸâªÉ«¬¡“
√—∫¬“ cycle ∑’Ë 2 ¬“∑’ˉ¥â√—∫ §◊Õ cyclophospha-
mide, vincristine ·≈– L-ASNase ‚¥¬„Àâ dexa-
methasone ‡ªìπ premedication
ª√–«—µ‘§√Õ∫§√—«: ªØ‘‡ ∏ª√–«—µ‘°“√‡®Á∫ªÉ«¬¢Õß
§π„π§√Õ∫§√—«
ª√–«—µ‘∑“ß —ߧ¡: ªØ‘‡ ∏ª√–«—µ‘°“√¥◊Ë¡ ÿ√“·≈– Ÿ∫
∫ÿÀ√’Ë
ª√–«— µ‘ ° “√·æâ : ªØ‘‡ ∏°“√·æâÕ“À“√·≈–ª√–«—µ‘
¿Ÿ¡‘·æâÕ◊ËπÊ ·µà¡’ª√–«—µ‘·æ⬓ vancomycin ¡’Õ“°“√
maculopapular rash
º≈°“√µ√«®√à“ß°“¬
Vital sign: BP 128/70 mmHg, P 100/
min, O2 sat 100%
GA: Good consciousness, dyspnea
Respiratory system: Clear both lung
Skin: Urticarial rash around mouth
Hospital course
¢≥–‰¥â L-ASNase 20 ¬Ÿπ‘µ/¡‘≈≈‘≈‘µ√ ‡«≈“
„π°“√„À⬓ 6 ™—Ë«‚¡ß À≈—ß„À⬓‰¥â 45 π“∑’ æ∫«à“
ºŸâªÉ«¬¡’º◊Ëπ≈¡æ‘…∑’ËΩÉ“¡◊Õ ª“° „∫ÀŸ µâπ§Õ ·≈–¢“
¡’µ“∫«¡ ¡’·πàπ§Õ ®ÿ°·πàπÀπâ“Õ° À“¬„®‰¡àÕÕ°
·æ∑¬å„Àâ chlorpheniramine 10 ¡‘≈≈‘°√—¡æ√âÕ¡°—∫
À¬ÿ¥°“√„À⬓ L-ASNase ®“°π—Èπ 1 ™—Ë«‚¡ß º◊Ëπ¬ÿ∫
≈ß Õ“°“√‚¥¬√«¡¥’¢÷Èπ
Vol 24 No 2 May - August 2014 °√≥’»÷°…“ : Õ“°“√‰¡àæ÷ߪ√– ß§å 101
Õ¬à“ß√ÿπ·√ß®“° L-asparaginase

2 ™—Ë « ‚¡ßµà Õ ¡“ ·æ∑¬å æ‘ ® “√≥“„Àâ ∫ √‘ À “√ Events v3.0 æ‘®“√≥“À¬ÿ¥¬“ L-ASNase ·≈–„Àâ

¬“ L-ASNase §«“¡‡¢â¡¢âπ‡¥‘¡∑“߇ âπ‡≈◊Õ¥¥”µàÕ
15 π“∑’À≈—ß„À⬓ ºŸâªÉ«¬¡’º◊Ëπ·¥ß‡ªìπªóôπµ“¡√à“ß°“¬
≈—°…≥–§≈⓬Փ°“√§√—Èß·√°∑’ˉ¥â√—∫¬“ ·æ∑¬å®÷ß„Àâ
dexamethasone 5 ¡‘≈≈‘°√—¡·≈–À¬ÿ¥¬“ L-ASNase
®“°π—Èπª√–¡“≥ 2 ™—Ë«‚¡ß Õ“°“√¢ÕߺŸâªÉ«¬À“¬‡ªìπ
ª°µ‘ º◊Ë π ¬ÿ ∫ ≈ß·≈– “¡“√∂À“¬„®ª°µ‘ ‰¡à ¡’ · πà π
Àπâ“Õ° ·æ∑¬åª√÷°…“Àπ૬·æ⬓
«—π√ÿàߢ÷Èπ·æ∑¬åæ‘®“√≥“„À⬓ L-ASNase
§«“¡‡¢â¡¢âπ·≈–§«“¡‡√Á«„π°“√„À⬓‡À¡◊Õπ§√—Èß·√°
·µà„Àâ premedication ‡ªìπ hydrocortisone 100
¡‘≈≈‘°√—¡ À≈—ß„À⬓‰¥â 30 π“∑’ ºŸâªÉ«¬¡’º◊Ëπ≈¡æ‘…∑’Ë
ΩÉ“¡◊Õ ª“° „∫ÀŸ µâπ§Õ ¡’·πàπ§Õ ®ÿ°·πàπÀπâ“Õ°
µ√«® —≠≠“≥™’ææ∫ lung clear, O2 sat 100%
·æ∑¬å«‘π‘®©—¬Õ“°“√·æ⇪ìπ anaphylaxis Õ¬Ÿà„π
√–¥—∫§«“¡√ÿπ·√ß∑’Ë 4 À“°®—¥√–¥—∫§«“¡√ÿπ·√ßµ“¡
NCI Common Terminology Criteria for Adverse
©’¥¬“ chlorpheniramine 10 ¡‘≈≈‘°√—¡ Õ“°“√º◊Ëπ
·¥ß ®ÿ°·πàπÀπâ“Õ°À“¬‰ª ·≈–ª√÷°…“Àπ૬·æ⬓
‡¿ —™°√Àπ૬·æ⬓ª√–‡¡‘𧫓¡ —¡æ—π∏å¢Õß
Õ“°“√‰¡àæ÷ߪ√– ß§å∑’ˇ°‘¥¢÷Èπ°—∫¬“∑’˺ŸâªÉ«¬‰¥â√—∫´÷Ëß
¬“∑’Ë¡’§«“¡ —¡æ—π∏å°—∫°“√‡°‘¥Õ“°“√‰¡àæ÷ߪ√– ß§å
§◊Õ L-ASNase ‚¥¬¡’Õ“°“√¢≥–„À⬓·≈–‰¡à¡’¬“Õ◊Ëπ
∑’Ë„Àâ√à«¡¥â«¬ À≈—ß„Àâ antihistamine Õ“°“√¥’¢÷Èπ
À“¬‡ªìπª°µ‘ ·≈–À≈—߉¥â√—∫¬“ L-ASNase Õ’°§√—Èß
ºŸâªÉ«¬‡°‘¥Õ“°“√‰¡àæ÷ߪ√– ß§å‡™àπ‡¥‘¡·≈–¡’Õ“°“√
√ÿπ·√ߢ÷Èπ ‡¡◊ËÕª√–‡¡‘π√–¥—∫§«“¡πà“®–‡ªìπ¢Õß°“√
‡°‘¥ Õ“°“√‰¡à æ÷ß ª√– ß§å ¥— ß °≈à “ «¥â «¬ Naranjoûs
algorithm ‚¥¬ª√–‡¡‘π‡Àµÿ°“√≥å„π§√—Èß·√°∑’˺ŸâªÉ«¬
‡°‘¥Õ“°“√·≈–·æ∑¬å„À⬓Ւ°§√—È߉¥â§–·ππ‡∑à“°—∫ 9
‚¥¬ √ÿª §◊Õ ¬“ L-ASNase ‡ªì𠓇Àµÿ¢Õß°“√‡°‘¥
Õ“°“√‰¡àæ÷ߪ√– ß§åπ’È·πàπÕπ (definite) ¥—ß· ¥ß„π
µ“√“ß 4

µ“√“ß 4 º≈°“√ª√–‡¡‘𧫓¡πà“®–‡ªìπ¢Õß°“√‡°‘¥Õ“°“√‰¡àæ÷ߪ√– ß§å°—∫¬“ L-ASNase ‚¥¬„™â Naranjoûs

algorithm ∑’Ë¥”‡π‘π°“√‚¥¬‡¿ —™°√
§”∂“¡ „™à ‰¡à„™à ‰¡à∑√“∫ L-ASNase
1. ‡§¬¡’ √ÿªÀ√◊Õ√“¬ß“π°“√‡°‘¥ªØ‘°‘√‘¬“π’È°—∫¬“™π‘¥π’È¡“·≈â«À√◊Õ‰¡à +1 0 0 +1
2. Õ“°“√‰¡àæ÷ߪ√– ß§åπ’ȇ°‘¥¢÷Èπ¿“¬À≈—ß®“°°“√‰¥â√—∫¬“∑’Ë ß —¬«à“‡ªìπ +2 -1 0 +2
 “‡ÀµÿÀ√◊Õ‰¡à
3. Õ“°“√‰¡àæ÷ߪ√– ß§å¥’¢÷Èπ‡¡◊ËÕÀ¬ÿ¥¬“∑’Ë ß —¬À√◊Õ‡¡◊ËÕ„À⬓µâ“π∑’Ë®”‡æ“–‡®“–®ß +1 0 0 +1
4. Õ“°“√‰¡àæ÷ߪ√– ß§å‡°‘¥¢÷ÈπÕ’°‡¡◊ËÕ„À⬓∑’Ë ß —¬‡¢â“‰ª„À¡àÀ√◊Õ‰¡à +2 -1 0 +2
5. ªØ‘°‘√‘¬“∑’ˇ°‘¥¢÷Èπ “¡“√∂‡°‘¥®“° “‡ÀµÿÕ◊ËππÕ°‡Àπ◊Õ®“°¬“∑’Ë ß —¬ -1 +2 0 +2
6. ªØ‘°‘√‘¬“¥—ß°≈à“«‡°‘¥¢÷Èπ‰¥âÕ’°‡¡◊ËÕ„À⬓À≈Õ° -1 +1 0 0
7.  “¡“√∂µ√«®«—¥√–¥—∫¬“„π‡≈◊Õ¥À√◊Õ¢Õ߇À≈«Õ◊Ëπ‰¥â§«“¡‡¢â¡¢âπ¢Õ߬“„π√–¥—∫ +1 0 0 0
∑’ˇªìπæ‘…
8. ªØ‘°‘√‘¬“√ÿπ·√ߢ÷Èπ‡¡◊ËÕ‡æ‘Ë¡¢π“¥¬“À√◊Õ≈¥≈߇¡◊ËÕ≈¥¢π“¥¢Õ߬“ +1 0 0 0
9. ºŸâªÉ«¬‡§¬¡’ªØ‘°‘√‘¬“∑’ˇÀ¡◊ÕπÀ√◊Õ§≈⓬§≈÷ß°—ππ’È¡“°àÕπ‡¡◊ËÕ‰¥â√—∫¬“π’È„π§√—Èß°àÕπ +1 0 0 0
10. Õ“°“√Õ—π‰¡àæ÷ߪ√– ß§å‰¥â√—∫°“√¬◊π¬—π‚¥¬À≈—°∞“π∑’ˇªìπ√Ÿª∏√√¡ +1 0 0 +1
(objective evidence) À√◊Õ‰¡à
√«¡§–·ππ 9
√–¥—∫§–·ππ >9 = „™à·πàπÕπ, 5-8 = πà“®–„™à,1-4= Õ“®®–„™à, 0 = πà“ ß —¬
102  ¡“§¡‡¿ —™°√√¡‚√ß欓∫“≈ (ª√–‡∑»‰∑¬) «“√ “√‡¿ —™°√√¡‚√ß欓∫“≈

ºŸâ ªÉ « ¬√“¬π’È ¡’ § «“¡®”‡ªì π µâ Õ ß„Àâ ¬ “ L- „π«—π·√°√–À«à“ß°“√∑” L-ASNase desen-

ASNase ‡π◊ËÕß®“°¿“«–‚√§µÕ∫ πÕßµàÕ°“√√—°…“
¥â«¬¬“π’ȉ¥â¥’ ‡¿ —™°√Àπ૬·æ⬓®÷߇ πÕ„Àâª√÷°…“
·æ∑¬å “¢“‚√§¿Ÿ¡‘·æâ·≈–¿Ÿ¡‘§ÿâ¡°—π∑“ߧ≈‘π‘°‡æ◊ËÕ∑”
L-ASNase desensitization ‚¥¬‡¿ —™°√Àπ૬
·æ⬓√à«¡°—∫·æ∑¬å ◊∫§âπ¢âÕ¡Ÿ≈°“√∑” desensiti-
zation ´÷Ëß¡’·π«∑“ß°“√„À⬓¥—ß· ¥ß„πµ“√“ß 5
‚¥¬‡µ√’¬¡ premedication ‡ªìπ chlorpheniramine
10 ¡‘≈≈‘°√—¡ ∑ÿ° 8 ™—Ë«‚¡ß √à«¡°—∫¬“ dexame-
thasone 5 ¡‘≈≈‘°√—¡ ∑ÿ° 6 ™—Ë«‚¡ß „Àâ∑“ßÀ≈Õ¥‡≈◊Õ¥
¥” ·≈–¡’°“√µ‘¥µ“¡§à“ —≠≠“≥™’æ·≈–Õ“°“√¢Õß
ºŸâªÉ«¬Õ¬à“ß„°≈♑¥∑ÿ° 1 ™—Ë«‚¡ß µ≈Õ¥ 4 ™—Ë«‚¡ß∑’Ë„Àâ
¬“ ·≈–‡µ√’¬¡¬“™à«¬™’«‘µ‡ªìπ chlorpheniramine
·≈– adrenaline
·æ∑¬å„Àâ L-ASNase desensitization ¥—ß
µ“√“ß 6 ‚¥¬„Àâ premedication 1 ™—Ë«‚¡ß °àÕπ°“√
∑” desensitization ·≈–„À⬓µàÕ‡π◊ËÕßµ“¡≈”¥—∫®π
§√∫ 5 ∂ÿ߇ªìπ‡«≈“ 10 «—πµ“¡·ºπ°“√√—°…“ ¡’°“√
µ‘¥µ“¡§à“ —≠≠“≥™’æ∑ÿ° 1 ™—Ë«‚¡ßµ≈Õ¥°“√„À⬓
·≈–‡µ√’¬¡¬“™à«¬™’«‘µ‡æ◊ËÕ√—°…“À“°ºŸâªÉ«¬¡’Õ“°“√‰¡à
æ÷ߪ√– ß§å‡°‘¥¢÷Èπ
sitization ‚¥¬„Àâ premedication ‡ªìπ chlor-
pheniramine 10 ¡‘≈≈‘°√—¡ ∑ÿ° 8 ™—Ë«‚¡ß √à«¡°—∫¬“
dexamethasone 5 ¡‘≈≈‘°√—¡ ∑ÿ° 6 ™—Ë«‚¡ß „Àâ∑“ß
À≈Õ¥‡≈◊Õ¥¥”¢≥–„À⬓ L-ASNase ∑’˧«“¡‡¢â¡¢âπ
20 ¬Ÿπ‘µ/¡‘≈≈‘≈‘µ√ (§«“¡‡¢âπ¢âπ¢Õ߬“„π∂ÿß∑’Ë 4)
À≈—ß®“°‰¥â√—∫‰ª 35 ¡‘≈≈‘≈‘µ√ ºŸâªÉ«¬‡√‘Ë¡¡’Õ“°“√§—π
µ“¡≈”µ—« ΩÉ“¡◊Õ∑—Èß 2 ¢â“ß·¥ß ·µà‰¡à¡’·πàπÀπâ“Õ°
·æ∑¬å©’¥ chlorpheniramine 10 ¡‘≈≈‘°√—¡∑“ßÀ≈Õ¥
‡≈◊Õ¥¥”∑—π∑’ ®“°π—ÈπÕ“°“√§—π·≈–º◊Ëπ·¥ß≈¥≈ß ®÷ß
æ‘®“√≥“„À⬓µàÕ À≈—ß®“°π—ÈπºŸâªÉ«¬¡’º◊Ëπ∑’˪“°·≈–
·¢π∑—Èß Õߢâ“ß ¡’Àπ—ßµ“∫«¡ „∫Àπâ“·¥ß¡“°¢÷Èπ
·µà —≠≠“≥™’檰µ‘ ¡’§à“ O2 sat 100% ·æ∑¬å®÷ß
æ‘®“√≥“À¬ÿ¥¬“
·æ∑¬å ‡ ª≈’Ë ¬ π·π«∑“ß°“√∑” L-ASNase
desensitization ¥—ß· ¥ß„πµ“√“ß 7 ‚¥¬„À⬓µàÕ
‡π◊Ë Õ ß°— 𠵓¡≈”¥— ∫ §«“¡‡¢â ¡ ¢â π ®π§√∫ 3 §«“¡
‡¢â¡¢âπ·≈–„Àâ√–¬–‡«≈“µ‘¥µàÕ°—π∑ÿ°«—π®π§√∫ 7 «—π
¢≥–„Àâ ¬ “¡’ ° “√µ‘ ¥ µ“¡§à “  — ≠ ≠“≥™’ æ ·≈–Õ“°“√
¢ÕߺŸâªÉ«¬Õ¬à“ß„°≈♑¥ ‚¥¬®–µ‘¥µ“¡∑ÿ° 1 ™—Ë«‚¡ß®π
§√∫ 4 ™—Ë«‚¡ß¢Õß°“√„À⬓ ·≈–¡’°“√‡µ√’¬¡¬“™à«¬

µ“√“ß 5 ·π«∑“ß„π°“√∑” desensitization ¢Õß L-ASNase10

§«“¡‡¢â¡¢â𠧫“¡‡√Á«„π°“√„À⬓ ‡«≈“„π ¢π“¥¬“
≈”¥—∫¢Õß (¬Ÿπ‘µ/ ª√‘¡“µ√ (¬Ÿπ‘µ/ (¡‘≈≈‘≈‘µ√/ °“√„À⬓ √«¡∑—ÈßÀ¡¥
∂ÿß∑’Ë„À⬓ ¡‘≈≈‘≈‘µ√) (¡‘≈≈‘≈‘µ√) ™—«Ë ‚¡ß) ™—Ë«‚¡ß) (™—«Ë ‚¡ß) (¬Ÿπ‘µ)
·π«∑“ß∑’Ë 1 1 0.02 250 1.2 60 4.2 5
2 0.2 225 12 60 3.8 50
3 2 225 120 60 3.8 500
4 20 225 1,200 60 3.8 5,000
·π«∑“ß∑’Ë 2 1 0.2 250 12 60 4.2 50
2 2 225 120 60 3.8 500
3 20 225 120 60 1 620
240 12 1 860
500 25 1 1,360
1,000 50 3.6 5,000
Vol 24 No 2 May - August 2014 °√≥’»÷°…“ : Õ“°“√‰¡àæ÷ߪ√– ß§å 103
Õ¬à“ß√ÿπ·√ß®“° L-asparaginase

µ“√“ß 6 ·ºπ°“√∑” L-ASNase desensitization ∑’Ë·æ∑¬å„ÀⷰຟâªÉ«¬√“¬π’È

§«“¡‡¢â¡¢â𠧫“¡‡√Á«„π°“√„À⬓‡«≈“„π ¢π“¥¬“
≈”¥—∫¢Õß (¬Ÿπ‘µ/ ª√‘¡“µ√ (¬Ÿπ‘µ/ (¡‘≈≈‘≈‘µ√/ °“√„À⬓ √«¡∑—ÈßÀ¡¥
∂ÿß∑’Ë„À⬓ ¡‘≈≈‘≈‘µ√) (¡‘≈≈‘≈‘µ√) ™—«Ë ‚¡ß) ™—Ë«‚¡ß) (™—«Ë ‚¡ß) (¬Ÿπ‘µ)
1 0.02 250 1.25 62.5 4 5
2 0.2 250 12.5 62.5 4 50
3 2 250 125 62.5 4 500
4 20 250 1,250 62.5 4 5,000
5 17.78 250 1,111.25 62.5 4 4,445

µ“√“ß 7 ·ºπ°“√∑” L-ASNase desensitization ∑’Ë·æ∑¬å„ÀⷰຟâªÉ«¬„π§√—Èß∑’Ë 2

§«“¡‡¢â¡¢â𠧫“¡‡√Á«„π°“√„À⬓‡«≈“„π ¢π“¥¬“
≈”¥—∫¢Õß (¬Ÿπ‘µ/ ª√‘¡“µ√ (¬Ÿπ‘µ/ (¡‘≈≈‘≈‘µ√/ °“√„À⬓ √«¡∑—ÈßÀ¡¥
∂ÿß∑’Ë„À⬓ ¡‘≈≈‘≈‘µ√) (¡‘≈≈‘≈‘µ√) ™—«Ë ‚¡ß) ™—Ë«‚¡ß) (™—«Ë ‚¡ß) (¬Ÿπ‘µ)
1 2 250 1.25 62.5 4 500
2 10 250 12.5 62.5 4 2,500
3 10 250 125 62.5 4 2,500

™’«‘µ‡ªìπ chlorpheniramine ·≈– adrenaline‰«â ∫∑ √ÿª

¥â«¬ ´÷Ëß„π√–À«à“ß∑’Ë¡’°“√∑” desensitization ¬“
L-ASNase ‡¿ —™°√Àπ૬·æ⬓®–¢÷Èπ‰ªµ‘¥µ“¡
Õ“°“√¢ÕߺŸâ ªÉ « ¬‡ªì π √–¬–¥â « ¬°“√ Õ∫∂“¡Õ“°“√
ºŸâªÉ«¬‚¥¬µ√ߢ≥–∑” desensitization ·≈–µ‘¥µ“¡
¢âÕ¡Ÿ≈®“°∫—π∑÷°°“√µ√«®¢Õß·æ∑¬å·≈–欓∫“≈
À≈— ß ®“°°“√∑” desensitization ¬“ L-
ASNase §√∫∑—Èß “¡§«“¡‡¢â¡¢âπµ“¡·ºπ°“√„Àâ
¬“§√—Èß∑’Ë 2 §√∫ 7 «—π æ∫«à“ºŸâªÉ«¬‰¡à¡’Õ“°“√º‘¥
ª°µ‘„¥Ê ·≈– “¡“√∂„À⬓µàÕ‰¥â ‡¿ —™°√Àπ૬·æâ
¬“‡æ‘Ë¡¢âÕ¡Ÿ≈§«“¡ ”‡√Á®„π°“√∑” desensitization
„π∫—µ√‡µ◊Õπ·æ⬓·≈–·®âߺŸâªÉ«¬‡°’ˬ«°—∫§«“¡®”‡ªìπ
„π°“√∑” desensitization „À¡à„π°√≥’∑’Ë¡’§«“¡
®”‡ªìπµâÕ߉¥â√—∫¬“ L-ASNase Õ’°„π§√—ÈßÀπâ“ √«¡
∑—Èß·π–π”Õ“°“√‰¡àæ÷ߪ√– ß§å∑’ËÕ“®‡°‘¥¢÷Èπ‰¥âÕ’° ‡æ◊ËÕ
„À⺟âªÉ«¬√–¡—¥√–«—ß·≈– —߇°µÕ“°“√Õ¬à“ß„°≈♑¥„π
¢≥–„À⬓
Õ“°“√‰¡àæ÷ߪ√– ß§å®“°¬“ ASNase æ∫∑—Èß
™π‘ ¥ ‰¡à √ÿ π ·√ß·≈–√ÿ π ·√ß®πÕ“®¡’ Õ— π µ√“¬∂÷ ß ™’ «‘ µ
 à ß º≈„Àâ ®”‡ªì π µâ Õ ßÀ¬ÿ ¥ „™â ¬ “ °√≥’ »÷ ° …“π’È ‡ ªì π
µ—«Õ¬à“ßÀπ÷ßË ¢Õß°“√‡°‘¥ HSRs ®“°¬“ native E. coli
ASNase (L-ASNase) ¡’ ° ≈‰°°“√·æâ ‡ °‘ ¥ ºà “ π
IgE-mediated °√–µÿâπ„ÀâÀ≈—Ëß histamine ¥—ßπ—Èπ
°“√√—°…“‡∫◊ÈÕßµâπ §◊Õ °“√„Àâ antihistamine ´÷Ëß„π
ºŸâªÉ«¬√“¬π’ÈÀ≈—߉¥â antihistamine Õ“°“√¢ÕߺŸâªÉ«¬
¥’¢÷Èπ ·µàÀ≈—ß„À⬓°≈—∫‡¢â“‰ª„À¡à°Á‡°‘¥Õ“°“√‡™àπ
‡¥‘¡·≈–√ÿπ·√ߢ÷Èπ ¥â«¬¢âÕ®”°—¥∑’˪√–‡∑»‰∑¬‰¡à¡’
º≈‘µ¿—≥±å¬“ ASNase √Ÿª·∫∫Õ◊Ëπ∑’Ë “¡“√∂„Àâ·∑π
‰¥â ·≈–ºŸâªÉ«¬¡’§«“¡®”‡ªìπµâÕß„™â¬“ ASNase ‡æ√“–
 “¡“√∂§«∫§ÿ¡‚√§„Àâ ß∫‰¥â ·æ∑¬å®÷ßµâÕß°“√„Àâ
¬“µàÕ·≈–ª√÷°…“‡¿ —™°√Àπ૬·æ⬓ ‡æ◊ËÕ ◊∫§âπ
¢âÕ¡Ÿ≈°“√„À⬓µàÕ„πºŸâªÉ«¬∑’Ë·æâ L-ASNase Õ¬à“߉√
°Áµ“¡ µâÕßæ‘®“√≥“∂÷ߪ√–‚¬™πå·≈–§«“¡‡ ’ˬߢÕß
104  ¡“§¡‡¿ —™°√√¡‚√ß欓∫“≈ (ª√–‡∑»‰∑¬)
ºŸâªÉ«¬∑’Ë®”‡ªìπµâÕ߉¥â√—∫¬“ L-ASNase ¥â«¬ ºŸâªÉ«¬
√“¬π’È ‡ °‘ ¥ Õ“°“√ anaphylaxis ´÷Ë ß ∂◊ Õ «à “ ¡’ § «“¡
√ÿπ·√ß¡“° (√–¥—∫ 4 µ“¡ NCI Common Termi-
nology Criteria for Adverse Events) °“√„Àâ
premedication ‡æ’¬ßÕ¬à“߇¥’¬«π—ÈπÕ“®‰¡à‡æ’¬ßæÕ
∑”„Àâ ºŸâ ªÉ « ¬¡’ § «“¡‡ ’Ë ¬ ßµà Õ °“√‡°‘ ¥ Õ“°“√‰¡à æ÷ ß
ª√– ß§å·≈–Õ“®¡’§«“¡√ÿπ·√ߢÕßÕ“°“√¡“°¢÷Èπ‰¥â
‡¿ —™°√Àπ૬·æ⬓®÷ß ◊∫§âπ¢âÕ¡Ÿ≈°“√„À⬓µàÕ‚¥¬
«‘∏’ desensitization ´÷Ë߇ªìπ°“√„À⬓∑’˺ŸâªÉ«¬·æâ
°≈—∫‡¢â“‰ª„À¡à„π¢π“¥µË” (¢π“¥¬“πâÕ¬°«à“¢π“¥∑’Ë
„Àâº≈°“√√—°…“ 1,000 ‡∑à“À√◊ÕÕ“®πâÕ¬°«à“π—Èπ) ·≈–
tritrate dose ‡æ‘Ë¡¢÷Èπ®π∂÷ߢπ“¥∑’Ë„Àâº≈°“√√—°…“
‡æ◊ËÕ„ÀâªØ‘°‘√‘¬“¢Õß·Õ𵑇®π·≈–·Õπµ‘∫Õ¥’ºà“π IgE
‡°‘¥¢÷ÈπÕ¬à“ß™â“Ê ®π‰¡à “¡“√∂°√–µÿâπ°“√·µ°¢Õß
mast cell ·≈–À≈—Ë ß  “√ histamine ∑’Ë °à Õ „Àâ ‡ °‘ ¥
°“√·æâÕÕ°¡“‰¥â ®–æ‘®“√≥“∑”„πºŸâªÉ«¬∑’Ë¡’§«“¡
®”‡ªìπµâÕ߉¥â√—∫¬“∑’Ë·æâ·≈–µâÕßÕ¬Ÿà„𧫓¡¥Ÿ·≈¢Õß
‡Õ° “√Õâ“ßÕ‘ß
1. Pui CH, Robison LL, Look AT. Acute lympho-
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«“√ “√‡¿ —™°√√¡‚√ß欓∫“≈
·æ∑¬å Õ ¬à “ ß„°≈â ™‘ ¥ ‚¥¬‡µ√’ ¬ ¡¬“™à « ¬™’ «‘ µ ‡™à π
chlorpheniramine, steroid, adrenaline, volume
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µ—¥ ‘π„®À¬ÿ¥°“√∑” desensitization À“°‡°‘¥°“√
·æâ∑’Ë√ÿπ·√ß ·≈–¢≥–∑” ®–µâÕßµ‘¥µ“¡Õ“°“√ √«¡
∑—È ß §à “  — ≠ ≠“≥™’ æ Õ¬à “ ß„°≈â ™‘ ¥ ‡æ◊Ë Õ ‡ΩÑ “ √–«— ß ·≈–
ªÑÕß°—π°“√‡°‘¥Õ“°“√‰¡àæ÷ߪ√– ß§å ∑—Èßπ’È ºŸâªÉ«¬∑’Ë
ª√– ∫§«“¡ ”‡√Á®„π°“√∑” desensitization ®–‡√‘Ë¡
„™â¬“„π¢π“¥∑’Ë„Àâº≈°“√√—°…“‰¥â ·µàÀ“°®”‡ªìπµâÕß
‰¥â√—∫¬“Õ’°§√—ÈßÀ≈—ß°“√∑” desensitization ‡°‘π 72
™—Ë«‚¡ß ®–µâÕß∑” desensitization „À¡à∑ÿ°§√—Èß ‡æ√“–
ºŸâªÉ«¬¬—ߧ߷æ⬓ L-ASNase Õ¬Ÿà ‡¿ —™°√Àπ૬
·æâ ¬ “§«√„ à ¢â Õ ¡Ÿ ≈ ‡æ‘Ë ¡ ‡µ‘ ¡ „π∫— µ √‡µ◊ Õ π·æâ ¬ “·≈–
„π√–∫∫§Õ¡æ‘«‡µÕ√å¢Õß‚√ß欓∫“≈‡°’ˬ«°—∫¢âÕ¡Ÿ≈
‡µ◊Õπ·æ⬓¢ÕߺŸâªÉ«¬ ‡æ◊ËÕ‡ªìπ¢âÕ¡Ÿ≈«à“ºŸâªÉ«¬ “¡“√∂
„™â ¬ “‰¥â ‚ ¥¬«‘ ∏’ desensitization ‡æ◊Ë Õ ª√–‚¬™πå
 Ÿß ÿ¥„π°“√„™â¬“∑’Ë®”‡ªìπ„π°“√√—°…“‚√§µàÕ‰ª
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